A nurse is creating a plan of care for a child who has sickle cell anemia. Which of the following interventions should the nurse include in the plan?
Discourage a high level of fluid intake.
Administer meperidine every 4 hr for pain.
Apply cold compresses to painful, swollen joints.
Observe for indications of hypokalemia.
The Correct Answer is D
Choice A reason: Discouraging a high level of fluid intake is incorrect, as hydration is essential for preventing sickle cell crises and reducing blood viscosity. The nurse should encourage the child to drink at least 1.5 times the normal fluid requirement.
Choice B reason: Administering meperidine every 4 hr for pain is incorrect, as meperidine is not recommended for sickle cell pain due to the risk of neurotoxicity and seizures. The nurse should use other opioids such as morphine or hydromorphone for pain management.
Choice C reason: Applying cold compresses to painful, swollen joints is incorrect, as cold can cause vasoconstriction and worsen the sickling of red blood cells. The nurse should use warm compresses or heating pads to promote vasodilation and blood flow.
Choice D reason: Observing for indications of hypokalemia is correct, as sickle cell anemia can cause hemolysis and potassium loss. The nurse should monitor the child's serum potassium level and watch for signs of hypokalemia such as muscle weakness, cramps, arrhythmias, and constipation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Placing the client in a private room is not necessary for a client who has a high WBC count, unless they have other indications for isolation, such as an infectious disease. A high WBC count may indicate inflammation, infection, or other conditions that affect the immune system.
Choice B reason: Monitoring the client's temperature every 4 hr is an appropriate action for a nurse to take for a client who has a high WBC count. A fever is a common sign of infection or inflammation, and it may require further intervention, such as antibiotics or antipyretics.
Choice C reason: Administering an antihistamine as prescribed is not related to a high WBC count. Antihistamines are used to treat allergic reactions, which may cause a low WBC count due to the release of histamine from mast cells.
Choice D reason: Encouraging the client to increase fluid intake is not specific to a high WBC count. Fluid intake should be based on the client's hydration status, urine output, and other factors. Increasing fluid intake may help flush out toxins or bacteria, but it is not a priority action for a client who has a high WBC count.
Correct Answer is B
Explanation
Choice A reason: Fifth disease is a viral infection that causes a rash on the face and body. It is also known as erythema infectiosum or slapped cheek syndrome. It is not the same as pertussis.
Choice B reason: Whooping cough is a bacterial infection that causes severe coughing spells that end with a whooping sound. It is also known as pertussis or the 100-day cough. It is the correct common name for the disease.
Choice C reason: Chickenpox is a viral infection that causes an itchy rash with blisters. It is also known as varicella. It is not the same as pertussis.
Choice D reason: Mumps is a viral infection that causes swelling of the salivary glands. It is also known as parotitis. It is not the same as pertussis.
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